Extendicare Hamilton (90 Chedmac Drive, Hamilton) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 160 beds.
Inspection Reports for Extendicare Hamilton
Our research team carefully reviewed and summarized inspection reports for Extendicare Hamilton. You can read the original copies of the reports in the Government of Ontario website.
November 2023
The inspection, conducted between November 1-3, 6, and 7, 2023, by Lead Inspector Barbara Grohmann, was a Critical Incident inspection focusing on falls prevention and management.
- Non-Compliance in Falls Prevention and Management: The inspection found that Extendicare Hamilton failed to comply with the required monitoring of a resident after unwitnessed falls. The facility’s Falls Prevention and Management Program, dated March 2023, required registered staff to monitor residents after an unwitnessed fall using clinical monitoring records. These records included documenting neuro-vital signs, vital signs, pain, motor responses, and a Glasgow Coma Scale score. The schedule mandated an initial neuro check, hourly checks for four hours, and every eight hours for 72 hours post-fall. However, the inspection revealed multiple lapses: three separate neuro checks were not completed, and five scheduled checks were performed late. A registered practical nurse acknowledged the importance of adhering to the monitoring schedule for accuracy. The acting Administrator also recognized the need to complete clinical monitoring as per the schedule. The failure to adhere to the monitoring requirements raised concerns that staff might not identify complications from an unwitnessed fall, particularly if a head injury was involved.
- Non-Compliance in Record Keeping for Falls Prevention: The licensee failed to maintain up-to-date written records regarding fall prevention interventions for a resident with a history of falls. Although post-fall assessments suggested a fall prevention device, it wasn’t clear if or how the intervention was implemented. The resident’s care plan lacked documentation on the use of any fall prevention devices. Staff responses about the use of these devices varied, indicating a lack of clear communication and documentation. The Falls Lead and acting Administrator acknowledged gaps in implementing and documenting fall prevention interventions. This failure raised concerns that necessary interventions might not be utilized effectively.
September 2023
The inspection, led by Inspector Lillian Akapong and assisted by Indiana Dixon, took place on August 8-16, 2023. It was a combination of a Complaint and Critical Incident inspection.
- Non-Compliance in Plan of Care: The licensee failed to provide the care specified in a resident’s plan of care, particularly in terms of 1:1 constant monitoring. This failure resulted in the resident experiencing a fall while unattended, despite the plan stating the need for constant monitoring and staff presence.
- Non-Compliance in Duty to Protect: The facility failed to protect a resident from abuse. An incident occurred where a resident pushed another resident, leading to a fall and injury. The event was witnessed by staff who were unable to intervene in time. The Assistant Director of Care acknowledged the facility’s failure to protect the resident from abuse.
- Non-Compliance in Foot Care and Nails: Extendicare Hamilton did not ensure that a resident received preventive and basic foot care services, including toenail cutting, as per the resident’s care plan. An inspection revealed that the resident’s toenails had not been cut for at least two weeks, despite the care plan stating that nails should be cut weekly. This negligence posed a health risk to the resident.
May 2023
The inspection, conducted from April 14 to 25, 2023, by Lead Inspector Lillian Akapong and Emma Volpatti, was a combination of a Complaint and Critical Incident System inspection.
- Plan of Care: The facility failed to provide 1:1 constant monitoring for a resident as specified in their plan of care. This lack of adherence led to the resident experiencing a fall. The Assistant Director of Care confirmed the need for continuous monitoring.
- Duty to Protect: A resident was injured after being pushed by another resident. The incident, although witnessed by staff, occurred without timely intervention. The Assistant Director of Care acknowledged this failure in preventing abuse.
- Foot Care and Nails: A resident’s toenails were not cut for at least two weeks, despite the care plan indicating a requirement for weekly nail cutting. There was no documentation showing subsequent nail care after this lapse was noted.
- Pain Management Program: No comprehensive pain assessment was conducted for a resident who reported pain after a fall, contrary to the facility’s policy requiring electronic pain assessment under such circumstances.
- Skin and Wound Care: Reassessment of skin impairments in residents was not conducted weekly by registered nursing staff as required, leading to potential risks of wound deterioration.
- Dining and Snack Service: No Registered Staff were present during meals in the dining room on two units. An RPN responsible for both units was occupied elsewhere, resulting in inadequate supervision during meals.
- Laundry Service: There was a shortage of clean linen and towels, significantly affecting resident care. The laundry quota log confirmed frequent under-quota supplies.
- Administration of Drugs: Medication was administered earlier than prescribed, leading to a resident experiencing an unresponsive hypoglycemic episode and subsequent hospitalization. Staff acknowledged the critical nature of following the prescribed medication schedule.
October 2022
The inspection was conducted by lead inspector Parminder Ghuman and additional inspector Waseema Khan. This inspection, which took place on September 8, 9, 12, 13, and 14, 2022, was triggered by a critical incident system and a complaint.
The inspectors focused on two main issues. The first was an unwitnessed fall of a resident resulting in a hip fracture (CIS # 2858-000008-22). The second issue was a complaint about the absence of an air conditioner in a room (Complaint # 016666-22). During the inspection, protocols for Falls Prevention and Management, Infection Prevention and Control (IPAC), and ensuring a Safe and Secure Home were utilized.
The inspectors made observations, reviewed records, and conducted interviews. They found no non-compliance issues during this process.
A non-compliance issue was identified and rectified during the inspection. On September 8, expired hand sanitizers were found in two home areas. The Registered Practical Nurse (RPN) and the IPAC Manager were notified and promptly removed the expired sanitizers. By September 9, all expired products had been removed from the facility, and the issue was resolved to the inspectors’ satisfaction.
August 2022
Conducted by lead inspector Daniela Lupu, this inspection focused on three main complaints: issues related to staffing and nutrition and dietary services (Log # 017959-21), concerns about resident care (Log # 018576-21), and allegations of abuse (Log # 005695-22).
- Altercations and Interactions Between Residents: The home failed to minimize the risk of altercations between residents. A resident with a history of responsive behaviors was involved in several altercations with other residents over a three-day period. Despite this, a specific intervention was discontinued for the day shift, and staff monitoring was inadequate. This resulted in moderate impact on one resident and potential harm to others.
- Responsive Behaviours: The home was non-compliant in documenting a resident’s responsive behaviors and their responses to interventions. Documentation was often incomplete or not done at specified time intervals, hindering the effectiveness of the interventions.
- Investigation of Alleged Abuse: The home failed to immediately investigate a reported incident of alleged abuse. This lack of investigation prevented the determination of the incident’s cause and the implementation of interventions to mitigate recurrence.
- Reporting Abuse to Director: Incidents of suspected abuse were not reported immediately to the Director as required. This could have delayed the Director’s ability to respond timely to the incidents.
- Dealing with Complaints: The home did not keep proper records of complaints about a resident’s abuse and safety concerns. The records lacked details of actions taken, resolutions, and follow-ups.
- Nutrition Manager: There was no nutrition manager at the home for five months, leading to challenges in food ordering and deliveries. This was a direct violation of regulations requiring a nutrition manager for the home.
- Air Temperature: The home did not maintain the required minimum air temperature of 22 degrees Celsius in various areas, including resident rooms and common areas. This posed a potential risk to residents due to low temperatures.
- Infection Prevention and Control: There was a failure to record symptoms of infection and take immediate action every shift for a resident at risk of infections. This lack of action and documentation led to delayed treatment and worsening of the resident’s condition.
- Implementation of IPAC Standards: Staff did not follow proper PPE use, such as not removing gloves after exiting resident rooms or walking in hallways with soiled items. There were also instances of inadequate availability of PPE at points of care.
- Directives by Minister: The home did not comply with the Minister’s Directive on management of symptomatic individuals and PPE requirements for suspected COVID-19 cases. This included not using the required molecular tests for COVID-19 and staff not wearing fit-tested N95 respirators when necessary.